needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to
take if these symptoms occur. The other information may also be included in patient teaching but
is not as essential in th
...
needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to
take if these symptoms occur. The other information may also be included in patient teaching but
is not as essential in the patient’s self-management of the illness.
2. The nurse performs a comprehensive assessment of an older patient who is considering
admission to an assisted living facility. Which question is the most important for the nurse to
ask?
a) “Have you had any recent infections?”
b) “How frequently do you see a doctor?”
c) “Do you have a history of heart disease?”
d) “Are you able to prepare your own meals?”
ANS: D
The patient’s functional abilities, rather than the presence of an acute or chronic illness, are more
useful in determining how well the patient might adapt to an assisted living situation. The other
questions will also provide helpful information but are not as useful in providing a basis for
determining patient needs or for developing interventions for the older patient.
3. An alert older patient who takes multiple medications for chronic cardiac and pulmonary
diseases lives with a daughter who works during the day. During a clinic visit, the patient
verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy
being alone all day. Which nursing diagnosis should the nurse assign as the priority for this
patient?
a) Social isolation related to fatigue
b) Risk for injury related to drug interactions
c) Caregiver role strain related to family employment schedule
d) Compromised family coping related to the patient’s care needs
ANS: B
The patient’s age and multiple medications indicate a risk for injury caused by interactions
between the multiple drugs being taken and a decreased drug metabolism rate. Problems with
social isolation, caregiver role strain, or compromised family coping are not physiologic
priorities. Drug–drug interactions could cause the most harm to the patient and are therefore the
priority.
4. Which method should the nurse use to gather the most complete assessment of an older
patient?
a) Review the patient’s health record for previous assessments.
b) Use a geriatric assessment instrument to evaluate the patient.
c) Ask the patient to write down medical problems and medications.
d) Interview both the patient and the primary caregiver for the patient.
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